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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL 209 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />� <br />JOB ADDRESS 1274n Tnkay colony Rd CITYIZIP LOdi,,CA 95240 <br />CROSS STREET R i 1 n t- n 1 n T, n APNn 6"12 2 n n l PARCEL SIZE 4 r, 7 LAND USE APPLICATION # <br />OWNERNAMEWllI J aM Barrer PHONE717119 -129-2966 <br />OWNERADDRESS 1271;2 P Tnka)4 Cnl nnv P,9 CmrISTATE/7JP Lodi, CA 95240 <br />Purylaric® D -i'l®rs, !;aG PHONE 20.Q 8EI_7 3554 <br />ADDRESSP Q Row 64 CITY/STATEMPLinf1PniC'A 95216 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE }C{C-57 ❑ G-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER -3 7 7 9 2 3 EXPIRATION DATE 7 13 1/ 2 i <br />DOMESTIC WELL SAMPLING: F General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) : Arsenic (4393) <br />INTENDED USE XDomestic(Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization Imo^ <br />❑ Public Water System NYHA <br />If different from Owner. Water System Name Contact Name or Phone Number r'1 2"1 <br />TYPE OF WORK 0 New Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other <br />`110 <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br /># of b C <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />SAfV J Z� <br />❑ New Pump XPumpReplacement 0 Pump Repair ❑ Raise Well Casing <br />194 <br />WELL CONSTRUCTION <br />ATN D NMFNT <br />�pART/ <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel <br />Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel C Plastic D Stainless Steel <br />❑ Other <br />Grout Seal Depth ft 0 Neat Cement (94 /b ba¢5-10 gal water) C Sand Cement <br />sack ma/7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped 0 Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length it Thick <br />in ❑ Christy Box ❑ Stove Pipe <br />PUNP ubmersible❑ Turbine D Other HP ri Pump Set it Standing Water Level __JILL_ it <br />Plot Plan Re irements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />1N)N"I A:. - "> I t24N' <br />DEPARTMENT USE ONLY <br />Application Accepted By L Date 'v( <br />Grout Inspection By Date <br />Pump Inspection By ! "^��'� I`� Date / <br />-a <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area l �i �` Employee ID# C%11 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth It <br />m <br />D <br />0 <br />0 <br />m <br />m <br />NT <br />EO <br />7 <br />PE Sc Received <br />Codes Irrfo BY, <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />3�► >> <br />l- <br />'7 2 25 22 vlPO k{ <br />EHDO43.06102512021 /J / _f 13 / 27SJ2�7 Page I of 2 %Veil I Pump Pe mit <br />